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Glossary

What is a Formulary?

A formulary is a list of drugs covered by your prescription plan. This list is made by doctors and pharmacists after reviewing clinical studies. They look at which drugs are most safe and effective, and maximize cost savings. The formulary has a range of generic and brand-name drugs (see below for descriptions) that have been approved by the US Food and Drug Administration (FDA). The formulary applies to prescription drugs that are dispensed in retail pharmacies and those delivered to your home through a home delivery pharmacy. If a drug is not on our formulary, it may have one or more FDA-approved alternatives that are covered by your prescription plan.

Generic DrugsThe FDA approves both brand-name and generic drugs. Generic drugs have the same active ingredients, dosage form and strength, and must be absorbed in the body the same way as brand-name drugs.

Generic drugs can be classified as single source or multiple source.

Single Source GenericsThese include brand-name drugs that are going off patent and a single manufacturer has exclusive rights to make the drug for a period of time.

Multiple Source GenericsThese drugs are defined by the Centers for Medicare and Medicaid Services (CMS) as products with three or more versions of the product related therapeutically equal (A–rated) no matter what the ratings of other versions (B–rated) and at least three suppliers are listed in the current editions of published national compendia.

Brand-Name DrugsA brand name is the trade name under which the drug is advertised and sold. A new drug is protected by a patent, so only one manufacturer can make it. For this reason, brand-name drugs most often cost more than generic drugs. Once a patent runs out, other companies may make a generic equal.

Copayments

A copayment is the out-of-pocket amount a member has to pay the retail pharmacy or to the mail order pharmacy for home delivery. The member pays one copayment per prescription. This fee is most often less than the actual price of the prescription and can vary based on the type of drug and the member’s benefits. Usually, generic drugs have a lower copayment than brand-name drugs. If the price of the prescription is less than the copayment, then the member will pay the lower price.

Tiered CopaymentTo give quality and affordable drug coverage, most EmblemHealth drug programs have a three-tiered drug formulary benefit. The three tiers, with different levels of coverage are:

Drug Management Programs

For the safe and cost-effective use of drugs, plans include programs for Prior Authorization, Drug Quantity Management and Step Therapy.

Prior AuthorizationPrior authorization is when some prescribed drugs must be authorized before they can be covered. Your prescribing doctor must give proof of the medical necessity of the drug for you and your diagnosis.

If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, prior authorization will be approved for your prescription to be filled.

Step TherapyA Step Therapy program is a two-step process. The first step is the use of a first-line or generic drug before a second-line drug is approved. The drugs used as the “first step” are well-established treatments. In most cases, these drugs are preferred therapy over second-line therapies. First-line drugs may be filled without calling EmblemHealth Pharmacy Benefit Services. The second step is if the first-line drug is not effective for you. In this case, second-line drugs can be prescribed. To do this, your doctor must call EmblemHealth's Pharmacy Clinical Department.

If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, prior authorization will be approved for your prescription to be filled.

Drug Quantity ManagementA Drug Quantity Management (DQM) program is when some drugs have quantity limits — meaning you can get only a certain amount at one time. The DQM program decides the number of doses to be included in each prescription for certain drugs. At the pharmacy, you might be told that your prescription is written for a larger amount than your plan covers. You can ask your pharmacist to give you the amount that your plan covers or, if your doctor doesn’t agree with the limit, he or she can call EmblemHealth's Pharmacy Clinical Department to find out if you can get a greater quantity.

If your doctor’s assessment meets approved guidelines for that drug and it is covered under your plan, prior authorization will be approved for your prescription to be filled. Review our list of covered drugs to find out if a drug has a quantity limit.

Specialty Injectable Pharmacy ProgramSpecialty drugs are most often injectable drugs for conditions such as multiple sclerosis, growth deficiencies, fertility issues and hepatitis C. Members who use specialty drugs must get their prescriptions filled through ICORE Pharmacy Services, EmblemHealth’s Specialty Pharmacy vendor.

You may not fill specialty drug prescriptions at a retail pharmacy or through Express Scripts home delivery. Some noninjectable drugs used in combination with self-injectables are also on hand through ICORE.

ICORE Pharmacy Services fills the prescriptions and delivers them directly to your home. You must join by calling ICORE at 1-866-554-2673.

For more information, call ICORE Pharmacy Services at the number above. You may also call EmblemHealth about your specialty pharmacy services at 1-888-447-0295.

Please Note: The descriptions above contain general information about our plans and programs. Complete details, conditions, limitations and exclusions are contained in the appropriate contract or certificate of insurance.

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